Doctor Second Opinion

While debate continues among the world’smesothelioma experts on which type of surgery is best, two new studies have added their findings to the pool of research on the topic.

Malignant pleural mesothelioma is a virulent cancer of the two-layered lining (pleura) that surrounds the lungs. Although it can take many years to develop, once it does, mesothelioma tends to spread quickly. The pleura may become thick and stiff as the cancer grows and fluid can develop between the layers, impeding the patient’s ability to breath. Mesothelioma can also spread to the diaphragm or the surface of the lungs and even into the lung tissue and can travel to other parts of the body via the lymphatic system.

There are two major types of surgical approaches to mesothelioma: 1) extrapleural pneumonectomy (EPP), which involves removing the pleura, diaphragm, lymph nodes, and the closest lung and 2) pleurectomy, which removes the pleura and any or all of the other diseased areas, with the exception of the lung. While several studies have indicated that EPP may offer a slight long-term survival advantage over pleurectomy/decortication (P/D), for those who survive the surgery, it also carries a high rate of serious complication and even death. On the other hand, proponents of EPP caution that P/D does not go far enough to eradicate mesothelioma. 

New research conducted in Turkey suggests that radical or extended pleurectomy (E/P) may offer a compromise. E/P is the most extensive version of lung-sparing pleurectomy, involving the removal of the pleura and all diseased tissue, including the diaphragm and lymph nodes. The study involved 76 mesothelioma patients with a median age of 53. Thirty-one patients underwent EPP, 20 had E/P and 25 were treated with P/D. 

The study found that, for E/P cases, the median survival was 27 months, compared to a median survival of 17 months for EPP and 15 months for standard P/D. The three-year survival rate was 34% among the E/P patients and 21% among those who had EPP. Only 13% of the P/D patients survived for 3 years.

At the same time, another recent article says surgeons should not shy away from EPP for mesothelioma, but should be aware of and prepared for the technical difficulties of this more extensive surgery. In an article entitled “Technical pitfalls and solutions in extrapleural pneumonectomy”, the authors state that many of the most dangerous complications of EPP – problems with the diaphragm patch, chylothorax (a type of pleural effusion), and empyema (buildup of pus in the pleural space) – can be managed if caught early. 

Sources: 

Bedirham, MA, et al, “Which type of surgery should become the preferred procedure for malignant pleural mesothelioma: extrapleural pneumonectomy or extended pleurectomy?”, August 2012, Journal of Thoracic Disease, pp. 446-454. 
Collaud, Stephane and de Perrot, Marc, “Technical pitfalls and solutions in extrapleural pneumonectomy”, November 2012, Annals of Cardiothoracic Surgery, pp. 537-543.

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